| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.141(c)(6) | 141c6 No TB test was in the records at the time of the review. | The physical examination shall include: Tuberculin skin testing by Mantoux method with negative results every 2 years for individuals 1 year of age or older; or, if tuberculin skin test is positive, an initial chest x-ray with results noted. | 141c.6
Individual was seen by urgent care on 6/5/2024. Tb testing was place on 6/5/2024 and read on
6/8/24 with Negative results. Individual Medical records are filed and locked at the residence |
06/04/2024
| Implemented |
| 6400.151(c)(2) | Staff records
151c2 There was no current tb from 2022 annual physical exam for staff number 1. | The physical examination shall include: Tuberculin skin testing by Mantoux method with negative results every 2 years; or, if tuberculin skin test is positive, an initial chest x-ray with results noted. Tuberculin skin testing may be completed and certified in writing by a registered nurse or a licensed practical nurse instead of a licensed physician, licensed physician's assistant or certified nurse practitioner. | Staff was seen at urgent care on 6/6/24 for TB testing. Negative results were obtained on 6/8/24. Staff health assessment documents are updated and placed on file. |
06/06/2024
| Implemented |
| 6400.181(a) | 181a Date of admission for the individual was 1/5/2024, the assessment was not completed at the time of review. (w/in 60 days of admissions). | Each individual shall have an initial assessment within 1 year prior to or 60 calendar days after admission to the residential home and an updated assessment annually thereafter. The initial assessment must include an assessment of adaptive behavior and level of skills completed within 6 months prior to admission to the residential home. | 181.(a) The Individual's assessment was completed on 3/29/24 and sent to the support team to update the ISP. |
06/04/2024
| Implemented |
| 6400.217 | 217 Consent for release of information was not completed for the individual at the time of the review. | Written consent of the individual, or the individual's parent or guardian if the individual is 17 years of age or younger or legally incompetent, is required for the release of information, including photographs, to persons not otherwise authorized to receive it.
| Individual has reviewed and signed the release of information form on 4/12/24. Individual records are completed, updated and stored accordingly. |
06/04/2024
| Implemented |